11.0 Unexpected Child Death

• 11.01 Introduction
• 11.02 Definition of an unexpected death of a child
• 11.03 What is a Rapid Response Service
• 11.04 Initial actions at the scene
• 11.04 Role of the ambulance crew
• 11.05 Role of the Police
• 11.06 The role of the GP
• 11.07 Moving the child to the hospital / mortuary
• 11.08 A Rapid Response: Phase One (usually 0-5 days)
• 11.08 In the mortuary
• 11.09 A&E Department
• 11.10 Assessment and Investigation
• 11.11 Initial Home Visit
• 11.12 Post mortem, pathologist, and coroner
• 11.13 When a child dies away from North Yorkshire and York
• 11.14 When a child living out of county is brought to a local hospital
• 11.15 Rapid Response Phase Two (within 5-7 days)
• 11.15 Initial Case Discussion
• 11.16 Rapid Response Phase Three (within 8-12 weeks)
• 11.16 Multi-agency Case Discussion Meeting
  

11.01 Introduction

11.1. This document identifies the procedure for ensuring a coordinated response by the North Yorkshire and City of York LSCBs (Local Safeguarding Children’s Boards) and their partners and other relevant persons to an unexpected death of a child.

Unexpected death can include:

• Homicide / Suicide
• Accidental death
• Natural causes

Ultimately the circumstances of the death will be examined by HM Coroner, but may form the basis of criminal prosecution and other legal proceedings. Any unexpected death of a child is a tragedy for the family members and therefore any enquiries or investigations need to balance forensic and medical requirements with the family’s need for support.

11.1.2. A minority of unexpected deaths are the consequence of abuse or neglect, or these are found as associated factors. In all cases, enquiries should seek to understand the reasons for the child’s death, address the possible needs of other children in the household, the needs of all family members, and also consider any lessons to be learnt about how best to safeguard and promote children’s welfare in the future.

11.1.3. Families should be treated with sensitivity, discretion, and respect at all times, and professionals involved should approach their enquiries with an open mind.

11.02Definition of an unexpected death of a child

11.2.1. An ‘unexpected death’ is the death of a child that was not anticipated as a significant possibility 24 hours before the death, or where there was a similarly unexpected collapse leading to or precipitating the events that led to the death.

11.2.2. The Unexpected Child Death Procedures apply to all unexpected deaths in children from birth until the 18th birthday.

11.2.3. A child who dies with a known disability or medical condition should be responded to in the same manner as any other child.

11.2.4. The Designated Doctor (Child Deaths) responsible for unexpected deaths in childhood should be consulted where professionals are uncertain about whether the death is unexpected. If in doubt, the death should be treated as unexpected and these procedures should be followed until the available evidence enables a different decision to be made.

11.03 What is a Rapid Response Service

11.3.1. Rapid Response describes the process of communication, collaborative action, and information sharing following the unexpected death of a child.

11.3.2. The purpose of Rapid Response is to ensure that the appropriate agencies are engaged and work together to:

• Respond quickly to the unexpected death of a child
• Make immediate enquiries into and evaluate the reasons for and circumstances of the death, in agreement with the coroner
• Undertake the types of enquiries that relate to the current responsibilities of each organisation when a child dies unexpectedly
• Collate information in a standard format
• Work together appropriately post death, keeping contact with family members and relevant professionals to ensure that they are appropriately informed

11.3.3. Rapid Response begins at the point of death and ends with the completed report to the Child Death Overview Panel.

11.3.4. The seven key strands to Rapid Response are (Appendix B):

• Care of the bereaved family: This includes the welfare and protection of remaining siblings, spiritual needs of the family and where appropriate, involvement of the extended family.
• Deciding of response: Deciding on whether the death is unexpected and whether to implement the rapid response procedure.
• Notification to a Single Point of Contact: The SPOC will be notified of all child deaths by the attending paediatrician, using the notification form (Appendix A)
• Child Protection: Emerging information giving rise to child protection concerns about remaining siblings/other children or peer group will require formal notification to Local Authority Children’s Social Care in line with local LSCB procedures.
• Serious Case Review: All agencies must be mindful of any emerging information giving rise for the LSCB to consider conducting a serious case review. The decision to undertake the review will be taken by the Chair of the LSCB where the child normally resides. Serious Case Reviews will operate simultaneously with the rapid response procedure.
• Media issues: There should be a coordinated response to media enquiries, agreed by all relevant agencies (where possible at the case discussions). Where appropriate, media enquiries should be directed to the relevant press office
• Support to staff: There will be varying degrees of impact upon staff and agencies need to have arrangements in place to manage this.

11.3.5. The investigation and management of unexpected death in childhood must follow a multi-agency approach, maintaining a balance between medical and forensic requirements whilst taking account of the needs of the family.

11.3.6. All cases of unexpected death in childhood must be referred to the coroner.

11.14 Initial actions at the scene
Role of the ambulance crew

11.4.1. The Ambulance Service Patient Contact Centre must inform the police of a call to attend an unexpected child death.

11.4.2. Ambulance crews will follow Joint Royal Colleagues Ambulance Liaison Committee Guidelines (JRCALC) and local guidelines relating to resuscitation.

11.4.3. All children up to the age of 18 will be transported to the nearest A&E Department, unless there is instruction not to do so by the police and resuscitation has not been initiated. In such cases the child will be taken to the hospital mortuary and the Designated Doctor for Child Deaths will be contacted.

11.4.4. The first professional on the scene must note the position of the child, the clothing worn, and circumstances in which the child was found.

11.4.5. Any actions or observations arousing suspicion must be reported to the receiving A&E Department and the police and social care, bearing in mind any perceived risk to other children within the household.

11.4.6. Any concerns after handing over the child should be reported through the Yorkshire Ambulance Service Child Protection Reporting Process.

11.05. Role of the Police

11.5.1. The provision of medical assistance to the child is obviously the first priority. If an ambulance is not present ensure one is called immediately, and consider attempting to revive the child unless it is absolutely clear from the prevailing circumstances that the child is dead. Ensure that the officer in charge of the investigation is informed of any resuscitation attempts in order that they can inform the pathologist.

11.5.2. As is the case for police attendance at any incident, officers must be aware of potential risks to health. These could include risk factors present at the scene but not obvious which could have contributed to the child’s death and may endanger attending emergency services. These for example there could be carbon monoxide build up, faulty electrical appliances or the presence of chemicals. Each case must be assessed on its merits and appropriate expert advice taken prior to the officers approaching the body.

11.5.3 Normally the first officer attending the scene will be responding to an emergency call relating to a child’s death. This officer will assume control of the situation and ensure the following actions take place:

• If the child is dead preserve the body and location as a crime or road traffic collision scene
• Establish suitable cordons and limit access to the scene
• Initiate a scene log
• Attendance at the body by medical professionals should be via a common approach path
• Contact Control Room and request a supervisor is informed and attends
• A decision will then be made as to the most appropriate specialist resource to be informed and attend
• In Road Traffic Collisions the duty Traffic SIO (Senior Investigating Officer) must be informed (normally of Sergeant rank). In the case of all other unexplained or suspicious deaths the duty Detective Inspector must attend the scene. If out of office hours the on call crime Senior Investigating Officer must be contacted
• In cases of unexplained or suspicious child death the relevant duty SIO (crime or traffic) will ultimately decide on who has access to the scene and in consultation with the Coroner when the body will be removed.

11.5.4. The preservation of the scene and the level and type of investigation will be relevant and appropriate to the presenting factors.

11.5.5. The investigation of any suspicious or unexplained child death should follow the guidance in the ACPO Murder Investigation and ACPO Road Death Investigation Manuals, and the NPIA Core Investigative Doctrine.

11.5.6. Scene preservation and examination should follow the established techniques in those manuals.

11.5.7. There are a number of additional factors to consider with a child’s death:

• Retain items such as the child’s used bottles, cups, food or medication
• The child’s nappy and clothing should remain on the child but arrangements should be made for them to be retained at the hospital. If the nappy has already been removed from the baby prior to police arrival ensure that it is recovered from the parents and handed to the police as a possible exhibit. The nappy or clothing may be required for future laboratory examination. Any other clothing should only be retained if it is of evidential value.
• Records of monitoring equipment from the Ambulance Service may be of evidential value and should be secured and preserved as this information may only be retained for 24 hours.
• In cases of suspicious death the family will not be allowed access to the scene without the approval of the SIO. In all other cases the SIO must be consulted prior to the family being allowed access or continued access to any scene.

11.5.8. The above is NOT an exhaustive list of considerations and should be treated only as a guide. They will not be necessary in every case. Refer to the earlier section ‘factors which may arouse suspicion’

11.5.9. If it is necessary to remove items from the house, do so with consideration for the parents. Explain that it may help to find out why their child has died. Ask the parents if they want the items returned.

11.5.10. As per 1.14, record any environmental features that may have contributed to the child’s death. Additionally record any evidence that indicates or could have contributed to the death such as temperature of scene, condition of accommodation, general hygiene and the availability of food/drink. Consider faulty appliances that may have caused the child’s death.

11.5.11. Parents are likely to want to hold and touch the body of their loved one. Whilst fully understandable these wishes must be balanced against any potential forensic contamination. Normally unless deemed suspicious this should be allowed, but only after consultation with the officer in charge of the investigation, and then only under supervision.

11.5.12. Offer to contact friends or relatives who might support parents, and employers to explain absence.

1.5.13. Ultimately the purpose of any police investigation is to fully establish the circumstances leading to the child’s death in order to assist the Coroner and / or the Crown Court.

11.06.The role of the GP

11.6.1. There are times when a GP is called to the child first. In such circumstances the GP should adhere to the same general principles as the ambulance staff (see above).

11.6.2. It is essential for the GP to contact the police or Coroner’s officer if they are the first on the scene, after taking into account their primary responsibility of saving life or declaring death. The best route is the Police Call Centre.

11.6.3. A GP may not issue the death certificate in these circumstances. Children who have died without explanation should be seen in the Accident & Emergency Department by a paediatrician and not sent directly to the mortuary. This enables the clinical history, examination and any initial investigations to be completed and information given to parents.

11.07.Moving the child to the hospital / mortuary

11.7.1. In all cases where the body is taken directly to a hospital or a mortuary, arrangements must be made for a consultant paediatrician to be informed of the child’s death, in order that an examination of the body can be made, tests arranged and medical information collated.

11.7.2. If the parents/carers wish to accompany the child’s body from the home to the mortuary, then this should be facilitated, unless the death is viewed as unnatural. In all cases the body should be transported to the hospital either by paramedics or undertakers as appropriate.

11.08.A Rapid Response: Phase One (usually 0-5 days)
In the mortuary

11.8.1. Any child whose death is unexplained should be taken to the Accident and Emergency Department (exceptionally they may be instructed not to do so by the police and where resuscitation has not been initiated) to confirm that no resuscitation is possible and to address medical, child protection and bereavement issues. If, for some reason, a child’s body is taken directly to the mortuary, the mortuary will inform the police and the Paediatrician.

11.8.2. The paediatrician’s role includes taking a full medical history and if possible conducting a brief clinical examination and arranging any appropriate initial investigations and an early joint home visit. The aim is to help identify at an early stage possible underlying medical conditions or child protection concerns. This information must be shared with the police as soon as possible.

11.09.A&E Department

11.9.1. On arrival the child should be taken to the appropriate resuscitation area and the emergency crash paediatric procedure should be initiated.

11.9.2. Call the paediatric crash team, Staff Grade/Senior SHO and Anaesthetist.

11.9.3. A qualified nurse must be allocated to look after the attending family and stay with the family, keeping them informed about what is happening.

11.9.4. The child must immediately be assessed by a senior paediatrician and death confirmed or appropriate resuscitation started; unless it is clear that the child has been dead for sometime (rigor mortis or blood pooling evident) resuscitation should always be initiated.

11.9.5. The identity of the people accompanying the child and their relationship to the child must be ascertained and recorded by the allocated nurse.

11.9.6. A detailed history should be taken during resuscitation, and as appropriate afterwards, with detailed records being made. Information must include a full medical history, a family history, history of any other child deaths, previous incidents of concern and an account of what happened and who was present. The history should be gathered by the Paediatrician and made available to the police.

11.9.7. When the child has been pronounced dead the Consultant Paediatrician should inform the parents/carers in attendance, having first reviewed all of the information available at that time.

11.9.8. The responsibility for further management and support of the family will usually rest with the Unexpected Death in Childhood Paediatrician (UDIC Paediatrician) in conjunction with the police, social care, and other primary health care teams.

11.9.9. The UDIC paediatrician will collect all hospital records, including A&E sheets, for the child and other siblings in the family and make them available to the police for any subsequent post mortem and enquiries.

11.9.10. The UDIC paediatrician will notify the Named Nurse for Child Protection, the Named Doctor for Child Protection and the GP

11.9.11. The UDIC paediatrician will also notify the Child Death Panel Administrator in the area for which the child’s death occurred. If this is not the area in which the child normally resides the Child Death Panel Administrator will notify the equivalent manager in the area where the child normally resides.

11.9.12. The Named Nurse Child Protection will inform the relevant Health Visitor/School Nurse, Designated Doctor and Nurse and will also liaise with social care to ensure that they have been informed of the death of the child. The Named Nurse will also secure all relevant records. In the event of a death in infancy, the Named Midwife or their deputy will be informed.

11.9.13. There will be a joint media strategy between police, health, and social care. Media enquiries will be directed through the appropriate agency press office as decided in the strategy. Normally this will be the police press office.

11.10 Assessment and Investigation

11.10.1. As soon as possible after the arrival of the child at the A&E Department, the senior nurse on duty must ensure that the police have been contacted.

11.10.2. The senior nurse on duty will contact Customer Relations/Advice or EDT (if out of office hours) who should be asked to immediately check their records relating to the child, the immediate family members, other members of the household and others with whom the child has lived. Any relevant information must be promptly shared with the police and paediatrician. The child protection register/Children’s Social Care Central Database should be checked by telephone on the child and other siblings in the family.

11.10.3. The Consultant Paediatrician, who will note any evidence of injury and the state of nutrition and hygiene of the child, should examine the child. Any injury or superficial lesion should be documented on a body chart.

11.10.4. Core body temperature should be taken immediately on presentation, using a low temperature thermometer if necessary.

11.10.5. The site and route of any intervention in resuscitation (e.g. venepuncture or intraosseous needle insertion) needs to be carefully recorded.

11.10.6. Full growth measurement (length, weight and head circumference) should be taken and plotted on centile lines. This must be taken for ALL unexpected deaths of children and young people, not solely for infants.

11.10.7. Some laboratory specimens may be taken during resuscitation, according to clinical need. In the case of SUDI there is an agreed schedule of samples to be taken (do we need to appendix these?)

11.10.8. Details of samples should be clearly documented and the site of investigation should be recorded in the notes.

11.10.9. Further investigation such as skeletal survey will be done according to the coroner’s wishes.

11.10.10. Intravenous and intra-arterial lines should not be removed unless agreed by the SIO. In all cases all sites of access should be fully documented. If any lines have been removed they should be retained as potential exhibits and their existence made aware to the police.

11.10.11. If an endotracheal tube has been inserted this should also be removed after its correct placement in the trachea has been confirmed by direct laryngoscopy (preferably by someone other than the person who inserted it). Again this should be retained as an exhibit if already removed.

11.10.12. Photographs of the child, prints of the hand and foot and a small lock of hair, as mementoes for the family, can be obtained unless there are exceptional circumstances. These samples will normally be taken following post mortem and not before so it is important to record any wishes expressed by the family.

11.10.13. Clothing must be left on the child. If removed to allow examination it should be placed in labelled specimen bags. Other items such as bedding brought in with the child should be placed in labelled specimen bags to be given to the Investigating Officer.

11.10.14. No items should be returned to the parents without consultation with the Senior Investigating Police Officer involved.

11.10.15. Before the family leave the A&E Department the Consultant Paediatrician on-call should see them together with the police investigation officer. In certain cases the police may wish to deploy a Family Liaison Officer who has a particular investigative role to perform.

11.10.16. Wherever possible the UDIC Paediatrician should also be present for this initial joint interview with the parents.

11.10.17. Written information such as leaflets published by the Foundation for the Study of Infant Deaths should be given to the parents at this time.

11.10.18. The family should be informed that the death must be notified to the coroner and that a post mortem will be required.

11.10.19. Review of the history and circumstances of the death by the Senior Investigating Police Officer, consultant paediatrician on-call and, where possible, the UDIC paediatrician should take place. Any child protection concerns for other children in the household must be discussed. If significant concerns emerge, this discussion will become the initial multi-agency strategy discussion under the Child Protection Section 47 Procedures.

11.11 Initial Home Visit

11.11.1. The police Investigating Officer and UDIC paediatrician should make a decision about whether to visit the home or the site of the child’s collapse or death; this should always take place for infants who die unexpectedly.

11.11.2. They will decide if any other health care professional should be asked to attend i.e. GP, Midwife, and Health Visitor. It is noted that the role this health professional took with the bereaved family in the pilot schemes was invaluable. This is usually the first time the family have returned to the scene and for some it may be the only time they return. If an FLO has been deployed by this stage they should attend as well.

11.11.3. The police and UDIC paediatrician should consider in detail the events leading to the infant’s death along with the systematic examination of the site of the child’s collapse/death.

11.11.4. The paediatrician’s role is to help to identify, understand and investigate factors that may have contributed to a natural, accidental or non accidental cause of death and ensure that the pathologist is fully informed before starting the post mortem examination.

11.11.5. After the home visit the police, UDIC paediatrician and any other professional who visited should review any significant concerns with regard to possible neglect or abuse having contributed to the child’s death.

11.11.6. It is important to make detailed records of the history and examination findings, which must be dated and signed. As far as possible accounts should be recorded using the parent’s/carer’s own words.

11.12 Post mortem, pathologist, and coroner

11.12.1. If there are no suspicious circumstances, after an evaluation of initial information; from the ambulance service, hospital and previous records, primary care, police and social care records – the post-mortem should be conducted by a pathologist with special expertise in paediatric pathology. If possible the post-mortem should be completed within 48 hours of the infant's death. If during the post-mortem the pathologist becomes at all concerned that there may be suspicious circumstances, they must halt the post-mortem and inform the Coroner.

11.12.2. If the Coroner has any concerns, having been made aware of all the facts, that the death may be of suspicious nature, then a Home Office pathologist will be used in conjunction with a paediatric pathologist. Where a pathologist is qualified both as a forensic and paediatric pathologist they may complete the post-mortem on their own.

11.12.3. Both the Coroner and the pathologist must be provided with a full history at the earliest possible stage. This will include a full medical history from the paediatrician, any relevant background information concerning the child and the family and any concerns raised by any agency. The Investigating Officer is responsible for ensuring that this is done. A pro-forma is available for the paediatrician. The medical notes will also usually be sent/taken to the pathologist by the police officer attending the post-mortem. Depending on the circumstances of death this could be one of the investigating officers or the Coroner’s Officer. Due to short timescales it is imperative all relevant information has been collected by the Paediatrician/ Nominated Nurse and handed to the police to take to the post mortem.

11.12.4. The Coroner’s Officer should inform all relevant professionals of the time and place of the post-mortem, including the Senior Investigating Police Officer and consultant paediatrician. The family should also be informed (via the FLO if one has been deployed).

11.12.5. The Investigating Officer should attend the post-mortem. If this is not possible, then he/she must send a representative who is aware of all of the facts of the case. In cases involving a Home Office Pathologist the SIO will decide appropriate resources to attend in line with the ACPC Murder Manual. As a minimum this would normally involve a CSI (Crime Scene Investigator), CSM (Crime Scene Manager) and exhibits officer. In all other cases the police will decide on the appropriate resources to attend.

11.12.6. The Pathologist at post-mortem will arrange a number of investigations.

11.12.7. If the paediatrician has arranged any medical investigations before or after death, the pathologist and Coroner must be informed and the results forwarded.

11.12.8. All professionals must endeavour to conclude their investigations expeditiously. This should include the post-mortem results such as histology. The release of the child’s body is a matter for the Coroner in consultation with the SIO.

11.12.9. The interim or final findings of the post-mortem should be provided immediately after the post-mortem examination is completed and the Coroner updated. The interim result may well be ‘awaiting histology/virology/toxicology’.

11.12.10. The police/Coroners Officer will prepare a report for the Coroner once all information relevant to the investigation (including the pathologists report) has been gathered. This report is intended to form the basis of a Coroner’s inquest. The target timescale for the completion of this report is two weeks after the conclusion of the investigation.

11.13 When a child dies away from North Yorkshire and York

11.13.1. When a child who is normally resident in the North Yorkshire and York area dies in another area with the United Kingdom, the area in which the child dies will follow the process detailed in the relevant Local Safeguarding Children Board procedure.

11.13.2. All such deaths must be notified to the North Yorkshire and York Child Death Review Panel Administrator as soon as possible after the child has been confirmed dead.

11.14 When a child living out of county is brought to a local hospital

1.14.1. When a child who lives out of the county dies in the area or where their body is brought to a local hospital (for example where they live just outside of the county), the North Yorkshire and York notification procedure will be followed. The designated doctor for child death should contact their counterpart in the area in which the child is resident and send notification to the LSCB for that area.

11.14.2. The LSCB managers for the two areas will decide which CDOP will review the child’s death on a case-by-case basis. As a minimum the hospital pediatricians receiving the child will be required to provide a report the LSCB, which will be forwarded to the LSCB of the area where the child was resident.

11.15 Rapid Response Phase Two (within 5-7 days)
Initial Case Discussion

1.15.1. In all cases a case discussion will take place following the preliminary results of the post-mortem examination. This will be arranged by the Designated Paediatrician for unexpected deaths in childhood and will involve the police, the pathologist, and any other relevant professionals. In many cases the discussion can be held by phone. Where a meeting is necessary, all health, and social care professionals and relevant professionals from other agencies should be invited to attend.

11.15.2. The purpose is to ensure all agencies are informed and updated, that all are working together and should information give rise to safeguarding issues, the appropriate procedure is implemented.

11.16 Rapid Response Phase Three (within 8-12 weeks)
Multi-agency Case Discussion Meeting

11.16.1. As soon as possible, usually within 8-12 weeks after the child’s death, once the results of all relevant investigations have been obtained, a case discussion meeting is to be held, which is convened and chaired by the UDIC Paediatrician and formally recorded.

1.16.2. The UDIC Paediatrician will chair the Multi-Agency Case Discussion.

1.16.3. The purpose of the meeting is to:

• Share information to the identify the cause of death
• Identify those factors that may have contributed to the death
• To plan future care for the family
• Identify potential lessons to be learnt
• Inform the Coroner’s inquest

11.16.3. In cases of suspicious death the amount of information released from the police investigation to this meeting will be sufficient to inform on the above issues ( it must be recognised there will be occasions where information cannot be disclosed due to ongoing investigative concerns).

11.16.4. This meeting should involve the G.P., Health Visitor/School Nurse/Midwife, Paediatrician, other relevant health professionals involved with the family, Pathologist, Senior Investigating Police Officer, Coroner’s Officer, Social Care Manager, Head Teacher and any other relevant professionals.

11.16.5. The meeting should always consider the possibility of abuse or neglect. If no evidence is identified to suggest abuse or neglect as contributory factors this should be documented as part of the report of the meeting. The following should also be documented:

• Any issues arising from the medical and social care given to the child and family
• Any shortcomings in the medical and social care given to the child and family identified
• Appropriate measures identified to improve future care
• Any issues of good practice

11.16.6. After the case discussion meeting the UDIC Paediatrician, in close consultation with the Pathologist and Coroner, should write a detailed report on the available information concerning the child’s death.

11.16.7. Arrangements should be made for the UDIC Paediatrician and the General Practitioner or Health Visitor/School Nurse/Midwife to jointly see the parents to explain the content of this report and to address any further questions.

1.16.8. The meeting minutes should be sent to each of the agencies involved with a copy to the Coroner and the Child Death Overview Panel.

11.16.9. The completed Child Death Agency Report (Appendix 4) should be forwarded to the Child Death Overview Panel

1.16.10. The Child Death Overview Panel (CDOP) will undertake an overview of all deaths of children normally resident within North Yorkshire and the City of York. This will be a paper exercise based on the information available from those who were involved in the care of the child, before and immediately after the death.